Note: Fields with no data or with a value of "Unknown" will not be displayed on the print out.
Project ID: 210808 DEA: 020E0904 EFIS: 0200000016
QA Service Level: 1
DIST-CO-RTE-PM: 02-SHA-5-R29.3/R31.1,R45.0/R45.8
Work Description: REPLACE BRIDGE, REALIGN ROADWAY AND SEISMIC RETROFIT
Location Description: IN SHASTA COUNTY ABT 8 MI N OF SHASTA LAKE CTY AND NEAR LAKEHEAD FRM TURNTABLE BAY O/C TO 0.1 MI N OF O'BRIEN SRRA & FRM 0.4 MI S TO 0.3 MI N OF DOG CREEK BRIDGE.
Contractor Name: GOLDEN STATE BRIDGE, INC.
Contractor Address: 3701 Mallard Drive, Benicia, CA 94510
Resident Engineer: Nathan Alexander Structure Rep.: Christopher S 'Chris' Brace
DIME Sample ID: 2019-04-25-17
TL Number from the TL Form: 001902
Sample Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Sample Organization Contact: (530) 225-3194
Type of Sample: Verification
Type of Material: Asphalt Binder
Sample Taken Date: 04/25/2019
Date that the sample was received by the laboratory/organization performing the testing: 04/25/2019
The quantity of what the sample constitutes: JMF Verification
A brief description of the sample: PG 58-34 M (Valero - Benicia)
From where was the sample collected: Manufacturer
Laboratory sample identification: D77852
Structure unique identifier:
Structure name:
The fabricator/manufacturer/facility name: Valero-Benicia Asphalt Plant
Performance Grade: PG 58-34 M
Modified: Yes
Lot number:
Sublot number:
Tank number:
Time of sample:
HMA Supplier:
Certified Asphalt Supplier:
Multigrade:
Multigrade Type:
Asphalt Binder Mix Number:
DIME Test ID: 2019-04-25-17-1
Test Method: AASHTO T228-09r13: Standard Method of Test for Specific Gravity of Semi-Solid Asphalt Materials (Specific Gravity)
Verified Date: 05/29/2019
Date Tested: 04/25/2019
Submitted By Organization: CT D02 - Redding Northern Regional Laboratory
Organization Address: 1657 Riverside Drive,
Organization City: Redding
Organization State: CA
Organization Zipcode: 96001
Organization Email: ward.jenkins@dot.ca.gov
Organization Phone: 530-225-3194
General Comments for this Test:
Test Result Compliance:
Additional Comments When Verified:
